“Really bad depression. Always struggled, this is the worst it has been”.
HPI – Depression/anxiety
For quality, patient reports symptoms are worse during the day. For severity, patient reports interference with sleep but denies suicidal ideations and able to maintain relationships. For context, patient reports major life stressors, legal problems, trouble at work, relationship stress, etoh use, and tobacco use. For associated symptoms, patient reports homicidal ideations, emotional lability, high irritability, anxiety, depression, and sleep disturbances but reports no significant weight gain or loss, no visual/auditory hallucinations, no delusions, and no shortness of breath.
Height
6’
Weight
314.6 lb
BMI
41.4
BP
102/85
Pulse
84
Resp
16
Temp
99.7
O2 sat
93% on RA
History
Current smoker
30 years 1 pack a day
Alcohol
“Occasional – once or twice a year”
Recreational drugs
“As a kid all of them”
Caffeine consumption
Moderate
Criminal history for meth distribution and use
Past medication history
Client reports: Seroquel, fluoxetine, citalopram, olanzapine, sertraline, – “almost killed me”, propranolol, risperidone, lithium, Depakote – “does not work”
Current medications
Bupropion 100 mg 1 tablet twice a day
Trazodone 100 mg twice a day
Alprazolam 2 mg tab TID
Levothyroxine 100 mg q day
Losartan 50 mg q day
Mounjaro 2.5 mg/0.5 ml subcutaneous pen injector q week
Omeprazole 40 mg twice a day
Oxycodone-acetaminophen 10mg-325 mg 5 times a day as needed
Testosterone cypionate 200 mg/ml intramuscular oil 1 ml q week
Tadalafil 5 mg q day
Nitroglycerin 0.4 mg sublingual as needed
DHEA 100 mg q day
Clomiphene citrate 50 mg every day
Vitamin D3 50,000 unit tablet every week
Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler 2 puffs every 4 hours
ROS
Constitutional
Constitutional: no fever, no chills, no significant weight gain or loss, normal appetite, night sweats, exercise intolerance, fatigue, sleep disturbances: insomnia
Eyes
Eyes: no dry eyes, no irritation, no pain in the eyes, no visual changes, no sensitivity to light (photophobia), no seeing double (diplopia), no discharge, objects moving within the field of view (floaters) (stigmatism)
ENMT
Ears: no difficulty hearing, no vertigo, ear pain, ringing in the ears (tinnitus) (multiple surgeries on sinus)
Nose: no difficulty smelling, no frequent nosebleeds, nose/sinus problems
Mouth/Throat: no sore throat, no difficulty swallowing (dysphagia), no anterior neck pain/tenderness, no unusual taste of foods, no bleeding gums, no change in voice, no dry mouth, no mouth ulcers, no oral abnormalities, no teeth problems, snoring
Cardiovascular
Cardiovascular: no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no known heart murmur, no calf or jaw pain, no ankle edema, palpitations, light-headed on standing
Respiratory
Respiratory: no rapid breathing, no sputum production, no coughing up blood, cough, wheezing, shortness of breath (sometimes SOB)
Gastrointestinal
Gastrointestinal: no nausea, no vomiting, not vomiting blood, normal appetite, no constipation, abdominal pain, frequent diarrhea, heartburn
Genitourinary
Genitourinary: no pain during urination, no incontinence, no difficulty urinating, no hematuria, no increased frequency, no feelings of urgency, no flank pain, no urinary tract infections
Musculoskeletal
Musculoskeletal: no muscle aches, no muscle weakness, no back pain, no swelling in the extremities, no difficulty walking, muscle cramps, arthralgias/joint pain (cramping in calves.)
Integumentary
Skin: no abnormal mole, no jaundice, no rashes, no discoloration, no excessive facial or body hair (hirsutism), no hair thinning, no growths / lesions, no excessive sweating, dry skin
Neurologic
Neurologic: no loss of consciousness, no slurred speech, no weakness, no tremors, no seizures, no dizziness, no headaches, no memory lapses or changes, no difficulty finding desired words, no loss of balance or falls, numbness, tingling (numbness and tingling in legs and arms.)
Psychiatric
Psych: Denies irritability, paranoia. Affirms depression, anxiety, panic attacks, sleep disturbances, feeling unsafe in relationship, thoughts of suicide, restless sleep (States he does not know what she will do. Does not trust spouse.)
Endocrine
Endocrine: no cold intolerance, no unusual body odor, fatigue, increased thirst, heat intolerance
Hematologic/Lymphatic
Hematologic/Lymphatic no bruising, no swollen glands, no clotting problems, no bleeding disorders
Allergic/Immunologic
Allergy/Immunologic: no runny nose, no nasal congestion, no frequent sneezing, no sinus pressure, no itching, no hives
Screenings
PHQ-2/PHQ-9 18
GAD-7 20
Mood Disorder Questionnaire – Positive screen for possible bipolar disorder
ACE for Adults 8/10
Conners 4 ADHD Index – Self-Report 11
4 in part A and 7 on part B – ADHD combined type. Client reports being on medication as a child for ADHD and a history of meth use.
What other assessment questions would you ask or use?
What is the diagnosis for this client? What are the differentials?
Create comprehensive Discussion Notes?
What is your treatment plan? Why? What other options?
